18 December 2010

Dr Grumble has a good decorator. He is more expensive than most decorators but he does a better job. He has never advertised. He doesn't need to. People recommend him to their friends and his small business thrives. Dr Grumble likes these artisan types. They are mostly self-employed. They provide something people need. They are honest Johns we trust.

If you run a business you need to make sure there is a demand for whatever goods or services you offer. If you want to sell something people don't need you somehow have to create a demand from nowhere. Regular readers may know that bottled water is the example Dr Grumble likes. When Grumble was a child bottled water was something foreigners had because their water supplies were unsafe. Now it is an essential item for youngsters. Even younger consultants go around the Grumble hospital with an emergency supply of water just in case they get stuck in the lift or the hospital's heating overcomes them. Go to the hospital shop and you will find several brands of water. Each contains, well, water. And it costs more than petrol. It is a collective lunacy on a massive scale. Yet if you challenge this behaviour it is you who will be seen as mad.

What you want.(With a cleverly hidden message in its name.)

What can we conclude from this? It is that people are very vulnerable to the powers of advertising and more subtle efforts to influence their behaviour. Don't think that Grumble considers himself immune. The Grumble children all waste their Grumble's hard earned money on water. Dr Grumble would surely have been inflicted with the same lunacy if he hadn't been born too soon for the malign influences of the bottled water industry to take hold.

If you can persuade people to buy water when they could drink it for free you can probably persuade them to do almost anything. In the Great War when people felt vulnerable there were lots of volunteers for the trenches. And in the Second World War Japanese volunteers for suicide missions were so numerous as to be compared with swarms of bees. When people become patients and are worried about their health they are particularly vulnerable to unscrupulous persuasion. The GMC recognised this in Advertising (1995) where it states:

People seeking medical attention can be particularly vulnerable to persuasive influence. (pdf)

Curiously, Advertising (1995) was withdrawn in 1997 about six months after Tony Blair took power. It didn't last long at all. Now why do you think that was?

As it turns out, Dr Grumble has been a patient recently. He broke a premolar. The NHS dentist had obviously been trained that he must give patients choice. Grumble was given four treatment options. One was private and three were NHS. One of the NHS options was immediately dismissed by the dentist because of the location of the nerve - so one wonders why this option was offered. The private option was 'unlikely to last as long'. Dr Grumble did not quite grasp the difference between the other two options. In any case he didn't have enough knowledge to make the choice between two possible treatments about which he knew very little. Dr Grumble gently made the dentist decide what was best. He is more likely to make the right decision than Grumble. Dr Grumble just wants his tooth fixed. And he trusts his dentist.

Most patients are like Dr Grumble. They have a problem and they want to be made better. Quite often there are various options. The occasional patient wants to know about all of them and wishes to weigh up the pros and cons of each treatment. These people tend to make themselves unhappy with their agonising over things they do not know much about. And if they need help in their agonising who will they ask? Dr Grumble of course. So Grumble will dutifully go into it with them and, at the end of the day (and it can take a long time), they will make a choice which would be the very same treatment option that Grumble would have chosen for them. Which is hardly surprising because the patient's information all came from Dr Grumble. The choice they think they exercised was really an illusion.

Our governments seem intent on developing wants. They tell us patients want choice. Patients want GPs open all hours. They want information. It all seems so reasonable that Grumble hesitates to question this mantra. Dare he suggest that the NHS should be giving patients what they need and not what they want?

The argument goes like this. People want bottled water. They don't need it. Patients may want antibiotics. But they may not need them. An insomniac might want sleeping pills but they are often not needed. Giving patients choice and dealing with their wants rather than needs is superficially laudable but it is not what the taxpayer should be paying for. And it is not good medicine either.

What you need.

Needs are fixed. You need to drink water. You don't need to drink lots of bottled water. Bottled water is a want that has been cleverly created. It is a waste of money and resources generally. If you want to buy bottle water, you can. It is your money. But in providing universal healthcare we must distinguish unnecessary wants from essential needs. Governments should avoid generating wants which, in a system that is free, can never be met. It is the needs that matter.

It was like this with Grumble's broken tooth. It needed mending. The dentist, following the NHS mantra, thought Grumble wanted choice but choice was not needed. Wants are things private businesses create. Needs are what governments should identify and provide to their electorate. In dentistry a set of pristine expensive new teeth is a want. Having a broken gnasher mended is a need.

Dr Grumble's dentist could have made some extra money from the private option if he had been less honest. He needn't have been quite so frank about the drawbacks of the private treatment. But he did what a professional should do. He was scrupulously honest. His talking down the private option made Grumble feel comfortable. Being given choice did not. He would have been even happier if the dentist had just told him what he was going to do. But that is not allowed any more. It is all about the market in healthcare. And that is much more about wants than needs.

The other day Grumble was having his hair cut and a journalist for the Independent came in and sat in the next chair. He and the barber moaned about the student loans. According to the journalist a large proportion of the students (I think he said half) will never earn enough money to pay back the loan. Your comment, Dr Aust, reminded me of this chance encounter and I see that there is indeed and article in the Independent which roughly tallies with what I recall. Apparently only a quarter of all graduates will pay off their loans.

What is the point of loans that so many will never be able to pay back? It's mad.

"What is the point of loans that so many will never be able to pay back? It's mad."

My understanding is that, like the ridiculous PFI schemes that did so much to discredit New Labour, the answer lies in where the borrowing is counted for audit purposes.

By not being DIRECT Govt borrowing (as it would be if the Govt were borrowing money to give to the Univs for teaching the students, as hitherto), but rather badged as a "money with which we will make repayable loans" (even if in reality they won't be repaid) the borrowing will miraculously become "off balance sheet", as the accountants say. So it won't count as part of public sector borrowing, the kind Govts don't like when they have to do it to fund the NHS, fight idiotic wars and bale out pocket-stuffing bankers.

Brilliant blog Dr Grumble. It is all too much about choice and wants rather than fuffiling immedite needs. When I was in my second placement (outpatient department which was consultant-led) there was alot of that, and not alot of much else going on. Patients were torn between wondering what to do alot of the time when there were several different options (all of which had the exact same outcome: cure the patient) that patients do not know what was best for them and struggle to make the decision when esentially it is the doctors who know what is best. Some patients will just say "do whats right" and some patients will make decisions that aren't always in their interest, but it is what they "want" so it is what they get and they are given options that aren't always as beneficial to them as others. When NHS services are being throttled up and down the land perhaps it's in everyones interest that less "choice" should be given if patients needs can be met by simply letting doctors run the show. What patients don't know won't hurt them.

I go to skin cancer clinics on a regular basis for check ups by a dermo consultant and nurse practitioner, whenever something arrises like a dodgy-looking mole I don't want to be given a choice, I just want it dealt with the best way possible and thankfully the doctor I have and NP know what to do. If something terrible was to ever occur (and it has in the past as I have had two melanoma-in-situ's excised and more dodgy-looking moles and marks than I can count) it would be an unbeliveable burden on me as a patient to make choices over the matter in such a manner that I would go home later feeling responsibile over the outcome. But it happens, patients are given too much choice and it is esentially their burden to bear.

Firstly, let me congratulate you on your ramble which, whilst clearly impassioned, was a waffle-y less concise retelling of that which had been imparted upon us by Dr Grumble. It did not need repeating.

Secondly, whilst for some patients being told what to do and which treatment to take is clearly the best way forward: it is by no means ever acceptable to implement this 'policy' across the board. What patients don't know can and will hurt them despite what you think.

People have a right to make the choice that is best for them and we have no right to not offer them a choice. We as clinicians should break down choices for them, extoll the virtues of each and the opposite. We can even suggest to them what 'we' would do or what 'we' think if they were to ask us.

We cannot just tell them you are having X,Y or Z for just because.

If we did this we'd have to base treatment on our judgements of a person and our assumptions. This is a folly that will lead to a poor outcome for any of those involved.

An example pour vous:

69 year old lady with urinary incontinence, caused by a pelvic organ prolapse. Lady goes for surgery after trying all other available treatments.

Surgeon makes an assumption;

"This lady is 64, no chance she's having sex with anyone. I'll therefore do what I think is best and do a really tight Vaginal tape so that it will last".

Patient ends up with vaginal stenosis, can now longer enjoy the copious amounts of sex she has and is in fact dealt a lot of pain in the trying.

Thanks for this lovely clear as spring water example. I've been writing about patient choice for some time. There are 3 articles on my blog, The problem with patient choice, and More problems with patient choice

I'm reading John Lanchester's book about banksters and the credit crunch. There's an interesting idea that economists are so wedded to their clever mathematical theories that they fail to take into account common-sense knowledge about human behaviour (i.e. we ain't rational) and so their theories failed spectacularly. Market advocates are victims of exactly the same folly. Could the close associations between politicians, bankers and economists have anything to do with the non-sensical assault on the NHS?

Patient choice links1.http://abetternhs.wordpress.com/2009/08/21/the-problem-of-choice/2.http://abetternhs.wordpress.com/2009/08/25/more-problems-with-patient-choice/3.http://abetternhs.wordpress.com/2010/11/10/more-problems-with-patient-choice-2/Lanchester's book is called "Whoops!" it fits very well in a stocking.

It's my understanding that Europe told Britain a couple of years ago that it could no longer use PFI and the like to keep the expenses off the national spend sheet. That's probably why it's starting to fall out of favour.

Anna Spanna and abetternhs; I think you should take a wee look at this article.

Loved the post Dr Grumble. How very true and as mentioned before how little understood by the Department of Health and PCTs. All the expensive walk in centres for people you feel a bit iffy in their lunch break!

"We as clinicians should break down choices for them" - that sounds good, but as a matter of interest do you tell patients how far their 'choice' is constrained by financial realities, DoH policy, and so on?

In effect 'choice' has never been just about the pros/cons of a particular procedure - there may be other options but options that not readily available in a given environment.

Let's say you are out in the sticks and clinical standards in your given setting are rather ordinary - do you advise your patients to trundle 30 miles down the road to avail themselves of a specialty service that is known to offer more advanced treatments?

In other words do you offer real choice, or choice as determined by the limited menu of options that exist in some parts of the NHS?

Oh, BTW Anna Spanna - let's say you know a colleague is not performing as well as they used to, or that you are unlucky enough to be lumbered with a sociopath for a boss - do you factor those sort of variables into the consultation equation?

No, I'm not paid by the government but merely a student in a health profession.

When I speak of choice, I can only mean of the options that would be available for me to draw upon in my practice and those which are actually available to the patient.

I can't offer that which isn't available: such is the imperfect world we live in.

If I am able and may send them towards something better then of course I must.

As for telling them by how much their choice is restricted I do not know. People are not all idiots and will have some inkling as to how health care is effected by the disease, disease severity, local policy and men in ivory towers.

Finally, it has not been unheard of for clinicians, particularly those in primary care, to know who is good and who is not for any given service and refer accordingly.

Let's face it: Most people spend way too much money on things they don't really need. The more money we make, the more we tend to spend.I really thank http://jewelsnistico.com help me with my Small Business.

I wish that I could find an optician with whom I am as comfortable as you are with your dentist.The last time that I visited our local branch of a well known chain (which I find is in fact a franchise), I got the impression that his advice was based more on the profit that he would make than my real needs and I won't be going back.I was even less impressed when I got a reminder letter in which he signed himself (disguising the names)"Mr Joe Bloggs,Branch Manager, Smith & Jones Ltd"To me this seemed to emphasise his priorities, especially as the branch comprises only him and a receptionist. I was always taught that it was out of order to refer to yourself as "Mr", as that was the privilege of others. There was no indication of his professional qualifications in the letter, whereas I, in a totally non-medical field, would always state my professional qualifications in business matters and leave the letter heading to define my position.How things change!

As a patient who has been proven correct in their own diagnosis of their condition twice which conflicted with a doctors, who had to listen to approximately an hour of literal scorn and ridicule from the medical profession before being proven correct on these occasions: I'm startled to discover on this blog that there are doctors who listen to their patients.

It makes me laugh when you see on the news that men should go to the doctor more and such, then immediately see in another news report a GP moaning about the "400 people they see who don't need treatment for the 1 who actually does".

Not sure if this puts any of the 400 off going to see their doctor, but it puts me off, as does the constant bickering and moaning about patients wasting their time at A&E, even sitting there waiting for an operation or to have a cast put on broken bone it makes me feel like a little bit of scum that left my estate by mistake and accidentally dirtied your shoes.

We can't be both ignorant, indigent little peasants, with no intelligence or insight into the bodies that we have inhabited for our complete existence that you do not have, yet simultaneously medically trained professionals who must diagnose ourselves as not needing a doctor when we don't, then when we do, come and see you [but don't you dare mention anything other than symptoms little peasant, self-diagnosis is blasphemy] so that the crude impulse of our grossly swollen limbic systems can be converted into human thought by your lofty lobes.

Doctors are people I'd love to look up to, yet mostly they are people I look up at. Giving patients more choice might be a headache for some workers in the field, but shockingly you aren't always right and the patient isn't always wrong.

Now M'Lords and Ladies, I must beg your leave. Forgive my disturbing you, for I am but a simple peasant. Perhaps one day there might be some joy to be found in withholding from us what you really think of us and we will return to looking up to you, not at you. Happy new year and thanks for saving lives! For all that is wrong with the health service, we do appreciate the work that you do.